Organization
PDC PROVO LLC
Active
Parent organization
PLATINUM DENTAL GROUP LLC
Organization subpart
Yes
Provider details
NPI number
Legal business name
PLATINUM DENTAL GROUP LLC
Authorized official
AMBER JOHNSON (OFFICE MANAGER)
(801) 426-6255
Entity
Organization
Contact information
Practice address
2520 N UNIV AVE, SUITE 101, PROVO, UT 84604
(801) 426-6255
(801) 224-2966
Mailing address
2520 N UNIV AVE, SUITE 101, PROVO, UT 84604
(801) 426-6255
(801) 224-2966
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
6026130
UT
1223G0001X
General Practice Dentistry
3192
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
529113131001
—
UT
Enumeration date
01/08/2007
Last updated
01/04/2013
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